Wednesday, April 10, 2019

Coding the Excision of Lesions

This edition of “Spotlight on CPT” is going to explore the proper coding for excision of lesions.  First, coding professionals must be aware of the basic notes associated with the excision of lesions.  These include:
  • Excisions are considered full-thickness
  • Margins are included when calculating the size of the lesion
  • Simple closure of excisions is included in the code for the removal
  • Repairs which are intermediate or complex are coded separately

There are several variables to take into consideration when coding for the excision of lesions in CPT.  The first variable that must be determined is whether the lesion is benign or malignant.  Benign lesion excisions are in the code range 11400-11446, while the code range for removal of malignant lesions is 11600-11646.

Consideration of another variable is the body part where the lesions are removed.  The body part selection is broken down into three categories.  These include:
  • Trunk, arms, and legs
  • Scalp, neck, hands, feet, genitalia
  • Face, ears, eyelids, nose, lips, mucous membrane

The final variable, which can be difficult to obtain, is the size of the lesion.  There are six different subdivisions of lesion size as follows:

  • 0.5 cm or less
  • 0.6-1.0 cm
  • 1.1-2.0 cm
  • 2.1-3.0 cm
  • 3.1-4.0 cm
  • Over 4.0 cm

Coders will recall that when determining the size of the lesion, the most narrow margins taken will be included in the calculation of the size.  For example, a lesion of the cheek with a size given as 0.5 cm removed with a 0.2 cm margin all around would have a final size of 0.9 cm.  See the illustration below.

This is very important, as using the margin can possibly impact the CPT assignment as the example above illustrates.  Even though the actual size of the lesion is 0.5 cm, the total area removed is 0.9 cm with the margins and thus moves the CPT code up one level. 

Therefore, if we apply the information provided above, and a physician removes a 0.5 cm benign lesion of the cheek, taking 0.2 cm margins all around, the correct CPT code assignment is 11441.  The full definition of this code is “Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.6 to 1.0 cm”.  Because we added the margins to the size of the lesion to arrive at the full excisional area, the correct CPT code is 11441 for the 0.9 cm removal, rather than 11440 for a 0.5 cm removal.

Determining the correct size of the lesion removal can not only result in the assignment of a different CPT code, but may also impact reimbursement as evidenced in the table below which depicts the ambulatory payment classification (APC) rate for the various excision codes.

               CPT Code                                   APC       Total Reimbursement            
Benign lesions    Malignant lesions
11440                  11640                            5071        $511.53               
11441                  11641                            5071        $511.53               
11442                  11642                            5071        $511.53               
11443                  11643                            5072        $1,203.74               
11444                  11644                            5072        $1,203.74               
11446                  11646                            5073        $2,076.01

Notice in our original example, there was no APC change, even though by coding the margin in addition to the lesion size the CPT code changed.  If, however, we looked at the same benign lesion of the cheek, but this time it was 3.7 cm with 0.2 cm margins, notice the difference.  The size of the lesion is 3.7 cm + 0.4 cm for the margins for 4.1 cm total size.  Not only does the inclusion of the margins change the CPT code from 11444 to 11446, but also our reimbursement is almost going to double from $1,203.74 to $2.076.01.     
It bears reminding that the codes for excision of lesions in the Integumentary System of CPT are for lesions of the skin, which include the epidermis and dermis layers.  For removal of lesions occurring below the skin (subcutaneous tissue, fascia, subfascial, intramuscular, or submuscular), coders should consult the Musculoskeletal System section of the CPT manual. 

One final point about the excision of lesions is that coders should assign a separate code for each lesion removed.  As long as removal of each lesion is separate, assign a code for each individual lesion.  Obviously, if removal of two lesions occurs with one excision (en bloc) then code only one excisional code for the entire size of the area removed.

Now, light has been shed on FESS coding in CPT.

About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.

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